[Sodium-glucose cotransporter 2 inhibitors for the management of heart failure]. / Los inhibidores SGLT2: una mirada al futuro del tratamiento de la insuficiencia cardiaca.

Heart failure (HF) is a global health problem. There is a strong association h between HF and type 2 diabetes mellitus (DM2), with an increasing prevalence of patients having both conditions concomitantly. Sodium-glucose cotransporter 2 inhibitors (ISGLT2) significantly reduce cardiovascular events, including cardiovascular death. In this article we will focus on the current evidence about the effectiveness of these medications in adults with heart failure with reduced or preserved ejection fraction.

[Transcatheter aortic valve implantation (TAVI) with conscious sedation and early discharge. Report of seven cases]. / Abordaje del implante valvular aórtico transcateter durante la pandemia por COVID-19 con alta prevoz: reporte de una serie de casos.

COVID-19 pandemic generated multiple challenges for the health system. Cardiovascular disease is associated with a worse prognosis of infections. Moreover, most hospital resources and operative rooms were destined to patients with COVID-19 infection, deferring the treatment of most valvular patients requiring surgery. We report seven patients with symptomatic severe aortic stenosis who underwent transcatheter aortic valve implantation (TAVI) with conscious sedation and early discharge. No patient required intensive care unit admission or mechanical ventilation. After a 90-day follow-up, there were no complications or unplanned readmissions.

[Use of anticoagulants in patients with atrial fibrillation undergoing transcatheter aortic valve implantation]. / Uso de anticoagulantes orales directos en pacientes con fibrilación auricular post implante de TAVI: resultados de una encuesta internacional.

BACKGROUND: Transcatheter Aortic Valve Implantation (TAVI) is beneficial in patients with symptomatic severe Aortic Stenosis (AS). There is no consensus about the best anticoagulation strategy for patients with a recent TAVI and with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) are effective to prevent embolic events with a significant lower incidence of bleeding. There is scarce evidence about the use of these drugs in patients undergoing TAVI. AIM: To assess the management of anticoagulation at the moment of discharge of patients with AF and TAVI. MATERIAL AND METHODS: A four question survey was sent to cardiologists involved in TAVI programs in different international centers. RESULTS: The survey was answered by 72 interventional cardiologists. Even with the lack of randomized evidence, in most of the scenarios DOACs are prescribed at discharge in patients with indication for anticoagulation. Also, in patients with high bleeding risk, most cardiologists would perform a left atrial appendage closure. In patients with concomitant coronary artery disease, if a stent was recently implanted, prescription of the combination of a DOAC and one antiplatelet drug was the most common answer. In patients with a former coronary angioplasty, DOAC or Warfarin was the therapy of choice. CONCLUSIONS: In the absence of randomized data, interventional cardiologists prescribe DOACs at discharge to patients with AF and TAVI, without following current guidelines in most cases.

[Combined use of left ventricular assist devices in cardiogenic shock. Report of one case]. / ECMELLA: Uso combinado de dispositivos de asistencia ventricular izquierda en el manejo del shock cardiogénico postinfarto agudo al miocardio.

We report a 55-year-old woman with a history of hypothyroidism and type 2 diabetes mellitus who consulted at the emergency room because of intermittent oppressive chest discomfort. At admission, electrocardiogram showed a complete atrioventricular block. A transthoracic echocardiogram disclosed severe left ventricular dysfunction. The patient developed cardiogenic shock that required the installation of the Impella system. An emergency coronary angiography showed an ostial occlusion of the anterior descending artery. Despite successful primary angioplasty, she persisted with refractory shock and progressive hypoxemia. A concomitant connection to the extracorporeal membrane oxygenation system (ECMO) was decided. The support of both devices allowed the stabilization of the patient and the improvement of perfusion parameters.

[Concomitant deployment of MitraClip devices and left atrial appendage closure. Report of one case]. / Implante concomitante de MitraClip y cierre de orejuela izquierda: importancia de la puncoón transeptal y sus implicancias técnicas. Caso clínico.

We report a 65-years old woman with a history of permanent atrial fibrillation with high risk for ischemic and bleeding events. She developed a heart failure with severely impaired left ventricular ejection fraction and severe secondary mitral regurgitation. Given her high surgical risk, using transesophageal echocardiography guidance, a concomitant deployment of two MitraClip devices using a high-posterior septal puncture and a left atrial appendage closure with an Amplatzer Amulet occluder were performed through the same access.

Effects of trimetazidine in nonischemic heart failure: a randomized study.

OBJECTIVES: Heart failure (HF) is associated with changes in myocardial metabolism that lead to impairment of contractile function. Trimetazidine (TMZ) modulates cardiac energetic efficiency and improves outcomes in ischemic heart disease. We evaluated the effects of TMZ on left ventricular ejection fraction (LVEF), cardiac metabolism, exercise capacity, O2 uptake, and quality of life in patients with nonischemic HF. METHODS AND RESULTS: Sixty patients with stable nonischemic HF under optimal medical therapy were included in this randomized double-blind study. Patients were randomized to TMZ (35 mg orally twice a day) or placebo for 6 months. LVEF, 6-minute walk test (6MWT), maximum O2 uptake in cardiopulmonary exercise test, different markers of metabolism, oxidative stress, and endothelial function, and quality of life were assessed at baseline and after TMZ treatment. Left ventricular peak glucose uptake was evaluated with the use of the maximum standardized uptake value (SUV) by 18-fluorodeoxyglucose positron emission tomography ((18)FDG-PET). Etiology was idiopathic in 85% and hypertensive in 15%. Both groups were similar in age, functional class, LVEF, and levels of N-terminal pro-B-type natriuretic peptide at baseline. After 6 months of TMZ treatment, no changes were observed in LVEF (31 ± 10% vs 34 ± 8%; P = .8), 6MWT (443 ± 25 m vs 506 ± 79 m; P = .03), maximum O2 uptake (19.1 ± 5.0 mL kg(-1) min(-1) vs 23.0 ± 7.2 mL kg(-1) min(-1); P = .11), functional class (percentages of patients in functional classes I/II/III/IV 10/3753/0 vs 7/40/50/3; P = .14), or quality of life (32 ± 26 points vs 24 ± 18 points; P = .25) in TMZ versus placebo, respectively. In the subgroup of patients evaluated with (18)FDG-PET, no significant differences were observed in SUV between both groups (7.0 ± 3.6 vs 8.2 ± 3.4 respectively; P = .47). CONCLUSIONS: In patients with nonischemic HF, the addition of TMZ to optimal medical treatment does not result in significant changes of LVEF, exercise capacity, O2 uptake, or quality of life.

[Spontaneous rupture of tricuspid valve papillary muscle in pulmonary hypertension secondary to HIV infection. Report of one case]. / Rotura espontánea de válvula tricúspide en un paciente con hipertensión pulmonar secundaria a VIH.

Acute primary tricuspid regurgitation (TR) secondary to papillary muscle rupture is an extremely rare clinical situation. We report a 42-year-old male with pulmonary artery hypertension (PAH) secondary to HIV infection, who presented with an acute TR due to spontaneous papillary muscle rupture. He remained in cardiogenic shock despite therapy with inotropic drugs and pulmonary vasodilator therapy. He was subjected to a tricuspid valve replacement. In the postoperative period the patient had severe PAH, which was successfully controlled with inhaled nitric oxide. Tricuspid valve replacement and adjunctive use of pulmonary vasodilator therapy can be a life saving and useful approach in this condition.

Ultrasound-Guided Transfemoral Access for Coronary Procedures: A Pooled Learning Curve Analysis From the FAUST and UNIVERSAL Trials.

BACKGROUND: The learning curve for new operators performing ultrasound-guided transfemoral access (TFA) remains uncertain. METHODS: We performed a pooled analysis of the FAUST (Femoral Arterial Access With Ultrasound Trial) and UNIVERSAL (Routine Ultrasound Guidance for Vascular Access for Cardiac Procedures) trials, both multicenter randomized controlled trials of 1:1 ultrasound-guided versus non-ultrasound-guided TFA for coronary procedures. Outcomes included the composite of major bleeding or vascular complications and successful common femoral artery cannulation. Participants were stratified by the operators' accrued case volume. We used adjusted repeated-measurement logistic regression, with random intercepts for operator clustering, for comparison against the non-ultrasound-guided TFA group and to model the learning curve. RESULTS: The FAUST and UNIVERSAL trials randomized a total of 1624 patients, of which 810 were randomized to non-ultrasound-guided TFA and 814 to ultrasound-guided TFA (cases 1-10, 391; 11-20, 183; and >20, 240). Participants who had operators who performed >20 ultrasound-guided TFAs had a decreased risk for the primary end point (5/240 [2.1%] versus 64/810 [7.9%]; adjusted odds ratio, 0.26 [95% CI, 0.09-0.61]) compared with non-ultrasound-guided TFA. Operators who performed >20 ultrasound-guided procedures had increased odds of successfully cannulating the common femoral artery (224/246 [91.1%] versus 327/382 [85.6%]; adjusted odds ratio, 1.76 [95% CI, 1.08-2.89]) compared with non-ultrasound-guided TFA. The learning curve plots demonstrated growing competence with increasing accrued cases. CONCLUSIONS: New operators should perform at least 20 ultrasound-guided TFA to decrease access site complications and increase proper cannulation compared with non-ultrasound-guided TFA. Additional accrued cases may lead to increased proficiency. Training programs should consider these findings in the transradial era.

Ultrasound-guided femoral access in patients with vascular closure devices: a prespecified analysis of the randomised UNIVERSAL trial.

BACKGROUND: Whether ultrasound (US)-guided femoral access compared to femoral access without US guidance decreases access site complications in patients receiving a vascular closure device (VCD) is unclear. AIMS: We aimed to compare the safety of VCD in patients undergoing US-guided versus non-US-guided femoral arterial access for coronary procedures. METHODS: We performed a prespecified subgroup analysis of the UNIVERSAL trial, a multicentre randomised controlled trial of 1:1 US-guided femoral access versus non-US-guided femoral access, stratified for planned VCD use, for coronary procedures on a background of fluoroscopic landmarking. The primary endpoint was a composite of major Bleeding Academic Research Consortium 2, 3 or 5 bleeding and vascular complications at 30 days. RESULTS: Of 621 patients, 328 (52.8%) received a VCD (86% ANGIO-SEAL, 14% ProGlide). In patients who received a VCD, those randomised to US-guided femoral access compared to non-US-guided femoral access experienced a reduction in major bleeding or vascular complications (20/170 [11.8%] vs 37/158 [23.4%], odds ratio [OR] 0.44, 95% confidence interval [CI]: 0.23-0.82). In patients who did not receive a VCD, there was no difference between the US- and non-US-guided femoral access groups, respectively (20/141 [14.2%] vs 13/152 [8.6%], OR 1.76, 95% CI: 0.80-4.03; interaction p=0.004). CONCLUSIONS: In patients receiving a VCD after coronary procedures, US-guided femoral access was associated with fewer bleeding and vascular complications compared to femoral access without US guidance. US guidance for femoral access may be particularly beneficial when VCD are used.

Extraction and analysis of free amino acids and 5'-nucleotides, the key contributors to the umami taste of seaweed.

Assessing the umami taste of seaweed on a chemical level can inform the use and selection of seaweed in European cuisine. Accordingly, we developed a method for the simultaneous extraction, separate clean-up and analysis of 21 free amino acids and 10 free nucleotides by reversed phase and mixed-mode HPLC respectively. Of multiple mouth emulating solvents, extracting in Milli-Q at 35 °C was found most suitable. This method showed good linearity (R2 > 0.9996), resolution (Rs ≥ 1.5) and picomole detection limits, and was successfully applied to determine the Equivalent Umami Concentration (EUC) and Taste Activity Values (TAV) of seven Dutch seaweed species. Phaeophyceae showed the highest EUC, followed by Chlorophyceae and Rhodophyceae (≈ 9.5, 3.7 and 1.1 g/100 g respectively). Glutamic acid always exceeded the TAV, while other umami compounds were species specific. Our method can accurately predict umami intensity and therefore contributes towards species selection for the European palette.

Routine Ultrasonography Guidance for Femoral Vascular Access for Cardiac Procedures: The UNIVERSAL Randomized Clinical Trial.

Importance: A significant limitation of femoral artery access for cardiac interventions is the increased risk of vascular complications and bleeding compared with radial access. Strategies to make femoral access safer are needed. Objective: To determine whether routinely using ultrasonography guidance for femoral arterial access for coronary angiography/intervention reduces bleeding or vascular complications. Design, Setting, and Participants: The Routine Ultrasound Guidance for Vascular Access for Cardiac Procedures (UNIVERSAL) randomized clinical trial is a multicenter, prospective, open-label trial of ultrasonography-guided femoral access vs no ultrasonography for coronary angiography or intervention with planned femoral access. Patients were randomized from June 26, 2018, to April 26, 2022. Patients with ST-elevation myocardial infarction were not eligible. Interventions: Ultrasonography guidance vs no ultrasonography guidance for femoral arterial access on a background of fluoroscopic landmarking. Main Outcomes and Measures: The primary composite outcome is the composite of major bleeding based on the Bleeding Academic Research Consortium 2, 3, or 5 criteria or major vascular complications within 30 days. Results: A total of 621 patients were randomized at 2 centers in Canada (mean [SD] age, 71 [10.24] years; 158 [25.4%] female). The primary outcome occurred in 40 of 311 patients (12.9%) in the ultrasonography group vs 50 of 310 patients (16.1%) without ultrasonography (odds ratio, 0.77 [95% CI, 0.49-1.20]; P = .25). The rates of Bleeding Academic Research Consortium 2, 3, or 5 bleeding were 10.0% (31 of 311) vs 10.7% (33 of 310) (odds ratio, 0.93 [95% CI, 0.55-1.56]; P = .78). The rates of major vascular complications were 6.4% (20 of 311) vs 9.4% (29 of 310) (odds ratio, 0.67 [95% CI, 0.37-1.20]; P = .18). Ultrasonography improved first-pass success (277 of 311 [86.6%] vs 222 of 310 [70.0%]; odds ratio, 2.76 [95% CI, 1.85-4.12]; P < .001) and reduced the number of arterial puncture attempts (mean [SD], 1.2 [0.5] vs 1.4 [0.8]; mean difference, -0.26 [95% CI, -0.37 to -0.16]; P < .001) and venipuncture (10 of 311 [3.1%] vs 37 of 310 [11.7%]; odds ratio, 0.24 [95% CI, 0.12-0.50]; P < .001) with similar times to access (mean [SD], 114 [185] vs 129 [206] seconds; mean difference, -15.1 [95% CI, -45.9 to 15.8]; P = .34). All prerandomization prespecified subgroups were consistent with the overall finding. Conclusions and Relevance: In this randomized clinical trial, use of ultrasonography for femoral access did not reduce bleeding or vascular complications. However, ultrasonography did reduce the risk of venipuncture and number of attempts. Larger trials may be required to demonstrate additional potential benefits of ultrasonography-guided access. Trial Registration: ClinicalTrials.gov Identifier: NCT03537118.

Design and Rationale of Routine UltrasouNd GuIdance for Vascular AccEss foR Cardiac Procedures: A Randomized TriaL (UNIVERSAL).

Background: A significant limitation of femoral artery access for cardiac interventions is the increased risk of vascular complications and bleeding compared to radial access. Ultrasound (US)-guided femoral access may reduce major vascular complications and bleeding. We aim to determine whether routinely using US guidance for femoral arterial access for coronary angiography or intervention will reduce Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding or major vascular complications. Methods: The Ultrasound Guidance for Vascular Access for Cardiac Procedures: A Randomized Trial (UNIVERSAL) is a multicentre, prospective, open-label, randomized trial with blinded outcomes assessment. Patients undergoing coronary angiography with or without intervention via a femoral approach with fluoroscopic guidance will be randomized 1:1 to US-guided femoral access, compared to no US. The primary outcome is the composite of major bleeding based on the BARC 2, 3, or 5 criteria or major vascular complications within 30 days. The trial is designed to have 80% power and a 2-sided alpha level of 5% to detect a 50% relative risk reduction for the primary outcome based on a control event rate of 14%. Results: We completed enrollment on April 29, 2022, with 621 randomized patients. The patients had a mean age of 71 years (25.4% female), with a high rate of comorbidities, as follows: 45% had a prior percutaneous coronary intervention; 57% had previous coronary artery bypass surgery; and 18% had peripheral vascular disease. Conclusions: The UNIVERSAL trial will be one of the largest randomized trials of US-guided femoral access and has the potential to change guidelines and increase US uptake for coronary procedures worldwide.

Introduction: Par rapport à l'abord radial, la limitation importante de l'abord artériel fémoral lors des interventions au cœur pose un risque accru de complications vasculaires et de saignements. L'abord fémoral guidé par ultrasons (US) peut contribuer à réduire les complications vasculaires majeures et les saignements. Nous avons pour objectif de déterminer si l'utilisation systématique du guidage par US pour l'abord artériel fémoral lors des angiographies ou des interventions coronariennes contribuera à réduire les saignements de type 2, 3 ou 5 selon le B leeding A cademic R esearch C onsortium (BARC) ou les complications vasculaires majeures. Méthodes: L' U ltrasou n d Gu i dance for V ascular Acc e ss fo r Cardiac Procedure s : A Randomized Tria l (UNIVERSAL) est un essai multicentrique, prospectif, ouvert, à répartition aléatoire, réalisé par une évaluation à l'insu des résultats. Les patients subissant une angiographie coronarienne avec ou sans intervention par voie fémorale sous guidage fluoroscopique seront répartis de façon aléatoire 1:1 à l'abord fémoral guidé par US ou sans US. Le principal critère d'évaluation est le critère composite de saignements majeurs de type 2, 3 ou 5 selon les critères du BARC ou de complications vasculaires majeures dans les 30 jours. L'essai est conçu de façon à avoir une puissance de 80 % et un seuil alpha bilatéral de 5 % pour déterminer la réduction du risque relatif de 50 % du critère d'évaluation principal selon un taux d'événements dans le groupe témoin de 14 %. Résultats: Le 29 avril 2022, nous avons terminé le recrutement de 621 patients choisis aléatoirement. Les patients avaient un âge moyen de 71 ans (25,4 % de femmes) et un taux élevé de comorbidités : 45 % avaient déjà subi une intervention coronarienne percutanée, 57 % avaient déjà subi un pontage aorto-coronarien et 18 % avaient une maladie vasculaire périphérique. Conclusions: L'essai UNIVERSAL qui sera l'un des plus vastes essais à répartition aléatoire sur l'abord fémoral guidé par US a le potentiel de faire changer les lignes directrices et de faire augmenter le recours aux US lors des interventions coronariennes dans le monde entier.

[Myocardial lipids and creatine measured by magnetic resonance spectroscopy among patients with heart failure]. / Determinaciones de niveles de creatina y lípidos mediante espectroscopia por resonancia magnética en miocardio de pacientes con insuficiencia cardiaca no isquémica.

BACKGROUND: Heart failure (HF) is characterized, among other features, by the development of alterations in myocardial energy metabolism, involving a decrease in glucose utilization and increased free fatty acid uptake by cardiomyocytes, associated with decreased deposits of high-energy phosphates (creatine phosphate/creatine transporter). Magnetic resonance (MR) imaging allows a direct and noninvasive assessment of myocardial metabolites. AIM: To measure myocardial creatine and lipids by MR spectroscopy among patients with HF. MATERIAL AND METHODS: Cardiac MR spectroscopy (1.5 Tesla) with Hydrogen antenna and single voxel acquisition was performed in five patients with non-ischemic heart failure, aged 58 ± 9.7 years, (60% males) and 5 healthy volunteers matched for age and sex. We analyzed the signals of creatine (Cr), lipids (L) and water (W) in the interventricular septum, establishing the water/lipid (W/L) and water/creatine (W/Cr) index to normalize the values obtained. RESULTS: Among patients, left ventricular ejection fraction was 32 ± 6.9%, 60% were in functional capacity II, 60% had hypertension and one was diabetic. Spectroscopic curves showed a depletion of total Cr, evidenced by the W/ Cr index, among patients with heart failure, when compared with healthy controls (1.46 ± 1.21 and 5.96 ± 2.25 respectively, p < 0,05). Differences in myocardial lipid content, measured as the W/L index, were not significant (5.06 ± 2.66 and 1.80 ± 1.62 respectively, p = 0.08). CONCLUSIONS: Among patients with heart failure of non-ischemic etiology, there is a depletion of creatine levels measured by MR spectroscopy.

Remote Ambulatory Cardiac Monitoring Before and After Transcatheter Aortic Valve Replacement.

Remote ambulatory cardiac monitoring (rACM) could identify high-grade atrioventricular block (AVB) before and after transcatheter aortic valve replacement (TAVR). Retrospective analysis of patients undergoing TAVR, with 14-day rACM before and after TAVR, was performed. Of 62 patients undergoing TAVR, 41 patients had rACM before TAVR. Three patients had asymptomatic AVB leading to planned pacemaker (PM) implant. After TAVR, 23 patients had rACM, with 1 patient requiring a PM implant for asymptomatic AVB. Five patients underwent unplanned PM after TAVR. Using rACM, almost half of PM implants in TAVR recipients were identified electively. High-grade AVB requiring PM was identified in nearly 10% of patients before TAVR.

La surveillance ambulatoire par télémétrie cardiaque pourrait permettre de détecter un bloc auriculoventriculaire (BAV) de haut grade avant et après le remplacement valvulaire aortique par cathéter (RVAC). Les données concernant des patients ayant subi un RVAC précédé ou suivi d'une période de surveillance ambulatoire de 14 jours ont été l'objet d'une analyse rétrospective. La surveillance ambulatoire a précédé le RVAC chez 41 patients sur 62 ayant subi l'intervention. Chez trois patients, un BAV asymptomatique a donné lieu à l'implantation planifiée d'un stimulateur cardiaque (SC). Le RVAC a été suivi d'une surveillance ambulatoire par télémétrie cardiaque chez 23 patients. La présence d'un BAV asymptomatique a nécessité l'implantation d'un SC chez un patient. L'implantation non planifiée d'un SC a été effectuée chez cinq patients après le RVAC. Grâce à la surveillance ambulatoire par télémétrie cardiaque, près de la moitié des cas nécessitant l'implantation d'un SC ont été dépistés accessoirement parmi les patients ayant subi un RVAC. Un BAV de haut grade nécessitant l'implantation d'un SC a été détecté chez près de 10 % des patients avant le RVAC.

Ultrasound Guidance in Femoral Artery Catheterization: A Systematic Review and a Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: During percutaneous cardiac procedures, the use of radial access is growing, but femoral access remains needed for large-bore, high-risk procedures. Methods are needed to make femoral access safer. In this systematic review and meta-analysis of randomized-controlled trials (RCTs), we assess whether ultrasound guidance is associated with a decreased risk of vascular complications during femoral artery catheterization. METHODS: Medline, Embase, and Cochrane Central were searched from inception to April 2018. RCTs assessing the use of ultrasound among adult patients undergoing a femoral artery catheterization were included. The primary outcome was vascular-access related complications. Secondary outcomes included major and minor vascular access bleeding, success rate, venipuncture, number of attempts, and successful placement into the common femoral artery. RESULTS: Five RCTs (n = 1553) met the inclusion criteria, with two trials using blinded outcome assessment. Ultrasound use was associated with a reduction in the rate of vascular-access related complications (1.9% vs 4.3%; odds ratio [OR], 0.44; 95% confidence interval [CI], 0.24-0.81; P<.01). This was primarily driven by a reduction in local hematomas; once hematomas were excluded, the association was no longer significant (0.6% vs 1.7%; OR, 0.39; 95% CI, 0.15-1.07; P=.07). There was no significant reduction in major bleeding (0.3% vs 1.3%; OR, 0.28; 95% CI, 0.07-0.1.16; P=.08) or minor bleeding (1.4% vs 2.8%; OR, 0.50; 95% CI, 0.24-1.05; P=.07). CONCLUSIONS: Ultrasound guidance during femoral artery catheterization is associated with a decreased risk of vascular complications, primarily driven by a reduction in local hematomas. Larger trials are needed to determine the effect of ultrasound on major bleeding and vascular complications (excluding hematomas).

Dolor tóraco-abdominal: "Si miras el corazón, encontrarás la razón". Serie de casos / Thoracic and abdominal pain, if you look at the heart you may find its cause: a case series

La isquemia miocárdica es un fenómeno secundario a la perfusión insuficiente del músculo cardíaco que en algunos casos puede ocurrir de forma aguda llevando a la necrosis celular y constituyendo el infarto agudo al miocardio (IAM). A pesar de que el diagnóstico de IAM es principalmente clínico, en ciertos casos en que no se sospeche de forma activa por presentar síntomas no típicos de isquemia miocárdica, el diagnóstico puede sugerirse por la Tomografía Computarizada (TC), que puede mostrar hallazgos sugerentes de IAM. A continuación, se comunica una serie de 4 casos clínicos con diagnóstico imagenológico incidental de IAM.

Myocardial ischemia is secondary to myocardial under perfusion. It can develop acutely leading to cell necrosis and myocardial infarction (AMI), or have a chronic course. Though the diagnosis of AMI is mainly clinical, in certain cases the symptoms may be atypical and the diagnosis can be suggested by images such as Computed Tomography (CT). Herein we report a series of 4 clinical cases with diagnosis of AMI following incidental CT imaging. There was an abdominal pain in 3 patients and a cervical pain in the remaining one. CT scan showed a hypodense myocardial image. The final diagnosis was confirmed by the appropriate laboratory and angiographic methods.

Histoplasma Endocarditis Diagnosed by Thrombus Aspiration.

Negative cultures in endocarditis often lead to delays in targeted life-saving therapies. We present the case of a 68-year-old man who presented with culture-negative endocarditis, which was complicated by coronary embolization resulting in anterior ST-elevation myocardial infarction (STEMI). Aspiration thrombectomy led to the diagnosis of fungal endocarditis, one of the most serious causes of culture-negative presentation.

Características y predictores ecocardiográficos de mortalidad en pacientes intervenidos con TAVI. La importancia de anticiparse al daño cardíaco global / Predictors of late mortality after TAVI: the relevance of early intervention to prevent global deterioration of cardiac function

Introducción: En nuestro medio, el implante percutáneo de prótesis aórtica (TAVI) se encuentra limitado a pacientes más añosos o de mayor riesgo quirúrgico, en quienes frecuentemente se retarda la intervención hasta que presenten signos avanzados de enfermedad. Objetivo: Evaluar el grado de compromiso miocárdico en pacientes sometidos a TAVI y determinar si la magnitud de este compromiso predice los resultados alejados del procedimiento. Métodos: Registro de pacientes sometidos a TAVI en 2 instituciones de Chile. Según la clasificación propuesta por Genereux el año 2017, se clasificaron desde el punto de vista ecocardiográfico como: 1) compromiso de ventrículo izquierdo; 2) compromiso de aurícula izquierda; 3) hipertensión pulmonar / insuficiencia tricuspídea significativa y 4) disfunción de ventrículo derecho. Resultados: Se incluyeron 209 pacientes. Se logró un procedimiento exitoso en 98,6%, registrándose una mortalidad intrahospitalaria de 2,9%. El compromiso cardíaco se extendió más allá de las cavidades izquierdas en 24,7% de los casos (estadíos 3 y 4). A una mediana de seguimiento de 650 días se registró una mortalidad de 26,8%. El compromiso de cavidades derechas (estadíos 3 y 4) se asoció a una mayor mortalidad (39,6% vs 22,1%, log rank p=0,015). En análisis multivariado, este compromiso fue el único factor que de forma independiente predijo mortalidad (HR 1,87, IC 1,01-3,44, p=0,044). Conclusiones: El compromiso de cavidades derechas se asocia a una mayor mortalidad alejada en pacientes sometidos a TAVI. Estos resultados debiesen estimular una derivación precoz de estos pacientes que, aunque añosos y de alto riesgo, tienen buenos resultados intervenidos precozmente.

Background: Locally, Transcatheter Aortic Valve Implantation (TAVI) is limited to very old or high-risk patients, whose intervention is frequently delayed until they develop signs of advanced disease. Aim: To evaluate the degree of myocardial compromise in patients undergoing TAVI and to determine whether the level of this compromise can predict results during follow-up. Methods: Registry of TAVI patients from 2 institutions in Chile. According to the classification proposed by Genereux in 2017, patients were classified based on the echocardiogram as 1) left ventricular compromise; 2) left atrial compromise; 3) pulmonary hypertension / severe tricuspid regurgitation; 4) right ventricular dysfunction. Results: The study included 209 patients. A successful procedure was achieved in 98.6% of cases, with an in-hospital mortality of 2.9%. Cardiac compromise extended beyond left chambers in 24.7% of cases (stages 3 and 4). During follow-up (median of 650 days) mortality was 26.8%. Right chambers involvement (stages 3 and 4) was associated with increased mortality (39.6% vs 22.1%, log rank p=0.015). In multivariate analysis, this compromise was the only factor that independently predicted mortality (HR 1.87, IC 1.01-3.44, p=0,044). Conclusions: Right chambers involvement was associated to increased mortality during follow-up of patients undergoing TAVI. These results should stimulate earlier referral of these high risk and older patients in order to obtain better results following the intervention.